7 Acute abnormality may be indicated by tenderness, a gap or step in the continuity of the cervical structures, oedema, haematoma or associated muscle spasm. Repeat this process 2–3 cm from the midline to determine whether facet pain can be elicited. 6 From a standing position behind the patient, place opposing thumbs on the spinous processes of C2, applying progressive systematic gentle circular pressure down the midline to ascertain the presence of tenderness. Physical examination of the cervical spine requires careful inspection and palpation from the nuchal ridge to at least the first thoracic vertebral prominence. In other settings a thorough history of the traumatic incident should be sought before clinical evaluation. In acute severe trauma, Advanced Trauma Life Support (ATLS) guidelines should be followed.
However, spinal cord injury is a very rare occurrence and is most often associated with major trauma. Other more subtle injuries, such as occult cervical soft tissue disruption, or associated vertebral or carotid arterial injuries can be difficult to detect, but may also result in permanent neurologic sequelae. The presence of cervical spine injury is often overt, indicated by neurologic deficit or radiographically demonstrated fracture or malalignment. 1,3 Potential serious injuries include vertebral body fracture, disc extrusion, cord contusion or compression, ligamentous rupture, epidural haematoma, facet displacement and vertebral or carotid arterial injury. 3,4 However, injuries at low velocity or force can also occur, such as falls from a low height or low speed rear-end traffic collisions, particularly when cervical spondylosis is present. 3 Higher velocity or greater force magnitude equates with a greater risk of injury. Injury results from hyperflexion, hyperextension, axial loading or rotational forces. 2 The most common mechanisms of injury include motor vehicle collisions, falls, sporting/recreational pursuits and assaults. Of the patients with cervical spine injury identified, 42% were found to have fracture, dislocation or pure discoligamentous injury requiring external immobilisation or operative stabilisation. A recent meta-analysis of 65 studies including almost 282 000 trauma patients, found that cervical spine injury occurs in 3.7% of patients overall, with 2.8% of alert patients and 7.7% of obtunded patients having an acute abnormality detected.